Health inspection·December 11, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure an allegation of resident abuse (when staff intentionally prevents a resident from having contact with friends, family, or others) by facility staff was reported to the State Survey Agency (SSA) immediately, but no later than two hours after the allegation was made for one of three sampled residents. This deficient practice had the potential to result in a delay in the abuse allegation investigation. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included schizophrenia (a chronic mental illness that affects how people think, feel, and behave) and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 1' s Minimum Data Set (MDS, a resident assessment tool), dated 10/04/2024, the MDS indicated Resident 1 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 1 required setup or clean-up assistance with eating, and supervision with personal hygiene. During a review of Resident 1's Situation, Background, Assessment, Recommendation Report (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/11/2024, the report indicated it was reported that Resident 1 was locked inside the family room. The report indicated staff assessed the resident's psychosocial wellbeing related to the allegation; physician made aware with order for psychologist consultation. During a review of Resident 1's Care Plan for Psychosocial Well-being, initiated 12/11/2024, the care plan indicated there was an allegation of isolation. The care plan indicated a goal that the resident will be able to interact with family, and other residents or staff daily. The care plan indicated an intervention to have a psychology consult and follow up. During a concurrent observation and interview in the Station Two Hallway, on 12/10/2024 at 11:30 a.m., observed Social Services Assistant (SSA) hand surveyor a piece of folded up paper. The paper indicated that the Director of Nursing (DON) locked Resident 1 in the family room, it happened in the afternoon and was witnessed by Certified Nursing Assistant 1 (CNA 1). The SSA stated on 12/9/2024 at (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056031 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)